Reflux Medications 101
Please note that we are not physicians and the following dosing information for all reflux medications (Antacids, H2 blockers and PPI’s) is based on various sources including our own children’s pediatricians, our children's GI Drs, the MARCI-kids team and various other web resources. These are dosing guidelines to let you know if you have the option of discussing an increase in the dose with your child's medical professional.
Over the counter (no prescription required) medication that counteracts stomach acidity by raising the pH of the stomach.
Should only be used short-term (2 weeks max)
Can be given with H2 receptor antagonist medications (see below)
Must be spaced four hours from any PPI medications
Excess use can cause diarrhea
Mylanta Cherry Supreme is recommended as it does not contain aluminum which has been link to possible CNS side effects.
Mylanta Cherry Supreme Dosing Suggestions:
newborn to 12 months
1/2 teaspoon (2.5 ml)
1 to 2 years old
1/2 - 1 teaspoon (3ml - 5ml)
2 years and older
1 teaspoon (5 ml)
*Maximum of 3tsp per day.
Simethicone (Gas Drops)
Over the counter anti-foaming agent used to reduce pain and discomfort caused by excess gas
Can be given with other medications without a need for spacing
While it is not a reflux medication, it can help reduce gas which may increase acid refluxing episodes
A prescribed oral GI medication used to treat duodenal ulcers.
Can be prescribed to help with damage due to acidic reflux by coating the inflamed intestinal lining (like a band-aid) to promote healing
Sucralfate does not neutralize acid and actually needs acid to properly work
Should only be used temporarily
Can cause constipation
Cannot be used with antacids, H2 receptor antagonist medications or with PPIs
H2 RECEPTOR ANTAGONIST MEDICATIONS
Prescription drugs used to block the action of histamine on parietal cells thereby decreasing the production of acid by these cells. They block the receptors and keep most of the signals to begin acid production from ever reaching the acid-producing pumps.
Good base line reflux medications; perhaps for use on baby with mild symptoms
FDA approved for use in children (Zantac and Axid)
Well tolerated, minimal side effects
They do not block all receptors; therefore, the acid-producing pumps can still be turned on
Require multiple doses a day
Many infants develop a tolerance for these drugs very quickly
Very weight sensitive
Will not reduce or lessen reflux episodes but should make the spit-up less acidic
Zantac (Ranitidine), Axid (Nizatidine), and Pepcid(Famotidine)
5-10mg/kg 5-10 mg/kg 0.5 to 1.0 mg/kg (divided 2-3 times a day)
Pepcid isn't generally recommended in males because it can cause abnormal breast tissue growth.
Because Zantac is the most prescribed medication for infant reflux, the below chart is a helpful guide for dosing based on weight. The total range is the range of medication that should be given as a total for the day. Zantac, like any H2 medication, should be dosed approximately 2 to 3 times a day.
WEIGHT (in lb): TOTAL DAILY RANGE (in ml)
Although many of the medications are the same as reflux medications given to adults just once per day (particularly the PPI’s - see below), it was found by the Midwest Acid Reflux Children’s Institute that these medications work best in infants and children if dosed 2 to 3 times per day. Because babies have a faster metabolism than adults, the effect of the medications tend to wear off more quickly and they often need multiple doses in a day for adequate coverage.
PROTON PUMP INHIBITORS
Prescription drugs used to reduce gastric acid production
They stop the release of acid from the pumps (rather than working on the receptors as H2 medications do)
Not necessarily stronger than H2 medications; PPI’s just work more efficiently at stopping acid production
Require an acidic environment to be activated
Usually more effective than H2 medications
Can be easier to administer than H2 medications
Block acid and promote healing faster and more effectively than H2 meds
Except for immediate release PPI, they must be given on an empty stomach 30 min. prior to a meal
Not FDA approved for children under 1 year old.
Can cause decreased appetite; long term use can cause calcium deficiencies
Can take up to 2 weeks to see results (when switching from an H2 medication to a PPI, you should continue to give your child the H2 medication for 2 weeks to provide coverage until the PPI is working. The only precaution is that you must space the H2 and PPI medications 4 hours apart).
Delayed vs. Immediate Release PPI
Delayed Release (Enterically Coated)
The active ingredient is contained within enteric coated granules/beads that are resistant to stomach acid. The coating only comes off when they reach the higher pH (less acidic) environment of the stomach/small intestine and the medication is then absorbed into the blood stream. Therefore they must be given on an empty stomach (approx. 30 min. prior to a meal). If they are exposed to acid immediately (such as when eating), the enteric coating will be degraded and the PPI will not be absorbed.
If necessary, the delayed release PPI (beads from within the capsule after opening) can be given with some acidic food (applesauce). If given with milk, formula or another non-acidic food, the enteric coating will dissolve and degrade before having the ability to reach the proton pumps.
Delayed release PPI’s should not be given within 4 hours of an antacid such as Myltana Cherry Supreme
Currently only available as Zegerid packets(omeprazole)
The PPI granulates are in a buffer solution that neutralizes the stomach acid (in place of the enteric coating) so that the granules/beads are not destroyed on their way to shut off the acid producing pumps. As zegerid is very new, clinical trials have not been completed for use in infants and it is therefore only currently approved for children over 12 years. Because of this and how new it is, some doctors and GI specialists will not prescribe for babies. Capsules are now available OTC.
Prilosec and Zegerid (Omeprazole)
Less than 3 mths: 1.5 mg/kg 2-3 times daily (3-4.5, g/kg total)
3 to 6 mths: 1.25 mg/kg 2-3 times daily
7 mths and older: 1 mg/kg 2-3 times daily
Less that 3 months: 1.5 to 1.75 mg/kg 2-3 times daily
3 to 6 mths: 1.25 to 1.5 2-3 times daily
7 mths and older: 1 to 1.25 2-3 times daily
*Dosing based on the MARCI-kids standards
Nexium is available in 10, 20 and 40 mg powder packets and 20 and 40 mg capsules.
For GERD in children up to 12, the recommended Nexium dose is 10 mg once daily for up to eight weeks.
For erosive esophagitis, the dose is the same unless the child weighs 44 pounds or more, in which case the dose is 20 mg daily.
* Suggested by Kristi Monson, PharmD: From WedMD
Must be given on empty stomach, 30 min. prior to meals
Solutabs can be given to baby direct or dissolved with a little water and given via syringe
Capsules: break open capsule (do not crush beads). Wet finger and touch beads. Sweep finger into baby’s cheek.
PPIs must be spaced at least 4 hrs apart from H2s
Delayed release PPI’s should not be given within four hours of an antacid such as Myltana Cherry Supreme
Compounding and/or Flavoring Medications (liquid medications)
This is not recommended (despite what the pediatrician, pediatric GI or pharmacist tell you). When a medication is compounded, the PPI granules/beads are suspended in a buffer solution (generally a neutralizing bicarbonate) to help prevent stomach acid degradation. However, many pharmacies do not add enough buffer to protect the PPI. Furthermore, the medications do not handle being in such an altered state and can degrade much more quickly. The active ingredient then becomes inactive and ineffective in a short time period than the dispensed thirty day bottle (typically 5-7 days according to studies done by the Midwest Acid Reflux Children’s Institution). Our suggestion is to find a pharmacy that specializes in compounding custom medications and have them fill the script for you.
Flavorings make the PPI unstable by breaking down the enteric coating in about 5-7 days and thereby making it ineffective when taken past this timeframe. If you have to obtain a compounded medication, please note that the maximum effectiveness for compounded PPIs are 5-7 days. Here are some recommendations for how you should ask that your pharmacist make the compound so that it will remain stable for longer. Make sure that your pharmacist does not put any kind of flavoring agent in the compound.
Make sure that the concentration is between 2 mg/mL and 4 mg/mL. This means that for every milliliter of suspension, you are giving between 2 and 4 milligrams of drug. Ask that your pharmacist make the compound with 16.8% sodium bicarbonate if the total volume of each dose is less than 7 mL. If the total volume of each dose is greater than 7 mL, ask that your pharmacist make the compound with at least 8.4% sodium bicarbonate. It is also not recommend that you give less than 3.5 mL of a PPI suspension at any concentration. This is because doses smaller than 3.5 mL do not provide enough buffer to adequately protect the drug from being destroyed by the acid that is present in the stomach (From the Midwest Acid Reflux Children’s Institute).
PROKINETICS (For Delayed Gastric Emptying)
Prokinetics or motility drugs, are medications that make the muscles of the GI tract contract more frequently and/or harder in order to help move food through the system more efficiently. Please note that these medications are NOT indicated for reflux. They are for a condition called Delayed Gastric Emptying or Gastroparesis (one of the side effects of which is reflux). Below are some symptoms of DGE:
Vomiting large amounts hours after eating
Abdominal gas pain and bloating
Feeling full after very small amounts of food
Lack of appetite
Irregular blood sugar levels
Difficulty gaining weight
Please note that some of these symptoms can also be caused by food allergies/MSPI (due to the inability to digest the proteins found in milk/soy or other foods). The only way confirm DGE is with diagnostic testing (Scinta Scan) that determines how long it takes the stomach to empty after ingestion of formula or food. See our tests page for more informaiton on the Scinta Scan.
This drug stimulates stomach muscle contractions to help emptying. Metoclopramide also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and bedtime. Side effects of this drug include fatigue, sleepiness, depression, anxiety, and problems with physical movement (NDDIC)*. Recent studies show that this medication can cause severe side effects and has been given a black box warning by the FDA. “The boxed warning will highlight the risk of tardive dyskinesia, Video Link or involuntary and repetitive movements of the body, with long-term or high-dose use of metoclopramide, even after the drugs are no longer taken” (from WebMD) at http://www.webmd.com/digestive-disorders/news/20090227/metoclopramide-drugs-get-black-box-warning.
Erythromycin / Eryped
This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects include nausea, vomiting, and abdominal cramps (NDDIC)*. Long term use of antibiotics can irritate the GI tracts and kill healthy, necessary bacteria as well as harmful bacteria. For these reasons, it’s recommended that this medication be used short-term only. Probiotic use may help to offset some of the side effects and re-establish healthy bacteria in the intestinal tract.
This drug works like Metoclopramide to improve stomach emptying and decrease nausea and vomiting. The FDA is reviewing Domperidone, which has been used elsewhere in the world to treat gastroparesis. Use of the drug is restricted in the United States (NDDIC)*.
Information on DGE in part from NDDIC: http://digestive.niddk.nih.gov/ddiseases/pubs/gastroparesis/
DOSAGE ADJUSTMENT: STEP-UP vs. STEP-DOWN APPROACH
Many pediatricians and Pediatric GI’s will follow what’s called a step-up approach to medicating reflux. That means that they will start with the lowest possible dose and work their way up to larger doses. Often this is done for fear of over-dosing an infant.
The step-down approach is to dose reflux medications at the maximum dose until the baby/child gets to baseline in terms of pain management (in other words symptoms of reflux pain such as arching and food refusal are no longer present). Once baseline level is achieved, then the GI who follows this approach may reduce the medication dose to get to the lowest level that will still maintain the optimal baseline state. This approach is often better because it allows the baby/child to become symptom-free in the shortest amount of time possible. This is particularly important with medications such as PPIs that can take up to 2 full weeks to see obvious results.
WEANING FROM MEDICATION
There’s no real “right time” to wean from reflux medication and no standard as to when/if reflux stops. You will be told by various physicians that your baby will outgrow his/her reflux by 6 months or 9 months or a year or 15 months, etc. The truth is, many babies will improve considerably once they become more upright and start standing up more, but reflux can also last into the toddler years and beyond. If you and your doctor decide that your baby is ready to stop reflux medications, it is recommended that the baby be weaned gradually, particularly for PPI’s.
If multiple doses are given per day, drop one of the doses (either go to 1/3 if dosing 3 times per day or a half if dosing 2 times per day) for 2 weeks. Then reduce to once a day for 2 weeks and then either every other day or stop completely. This will let the body start producing acid again gradually and will reduce the chances of acid rebound (over-production of acid) from stopping cold-turkey.